The pervasiveness of polypharmacy is well-documented, and it is generally held that too many patients are being prescribed unnecessary or duplicative medications. Regulatory reform, patient demographics and rising drug costs are coalescing to shine a light on polypharmacy and to generate discussion about how acute and post-acute inpatient health care facilities should respond.
Management of patients’ medication is typically built on a pharmacist-centric culture. The physician’s role is mostly front-loaded: prescribing medications and responding to medications-related adverse events. Otherwise, the physician's day-to-day participation in medication management is quite limited. In addition, cultural and organizational impediments can prevent timely communication between physician and pharmacist, resulting in a gray area where neither takes leadership.
The many responsibilities of facility-based pharmacists, and the urgency of their daily activities, limit their ability to meaningfully focus on polypharmacy. Pharmacy programs have neither the structure nor the resources to gain control of the issue, no doubt for a litany of reasons beyond pharmacists’ control.
'Deprescribing' medications and deciding who's in charge
Physicians, of course, hold prescription authority, but they also hold the less used (and less understood) authority to stop medications. Unfortunately, there is little in the way of formal training or established protocol for physicians to "deprescribe" medications in a systematic way.
Often, the facility-based physician defers to the patient’s primary care physician to optimize the patient’s medications list. But, too often, this simply doesn’t happen. Also, while "deprescription" is a key objective in optimizing, it is not the only one. The physician also can be looking to add needed medications, adjust dosage and effectively use generics, to name a few.
When a patient is transferred among facilities, PCPs tend to lose connection with the patient's medications regimen. New additions to the medications list may be buried in the details of a discharge notification. There may also be physician specialists adding prescriptions without notifying the PCP. Additionally, in many cases, PCPs lose track of over-the-counter medications and other supplements in the patient’s medicine cabinet.
All in all, a PCP may not have the best perspective on what his or her patient’s medications regimen really looks like.
The facility-based physician (the hospitalist in particular), on the other hand, possesses the skill set and the expertise to optimize medications, as well as extended access to the patient. This physician has built-in advantages to reconstruct the patient’s medications regimen in such a way as to ensure that the patient does not carry a suboptimal regimen to the next site of care.
4 Strategies for avoiding polypharmacy
Already hard-pressed to fulfill manifold obligations, the facility-based physician will need the active support of facility administrators and the pharmacy team to prevent polypharmacy. Here are four ways to enable physicians to engage with polypharmacy at the facility level while causing minimal disruption to the workflow of physicians and the rest of the care team:
- Build a comprehensive polypharmacy management plan directly into the patient’s transition-of-care program. Make the discharging physician directly responsible for line-item review and approval of the patient's medications list. As bundled payment plans play an increasingly prominent role in the inpatient care delivery system, it is important to address the impediments that accompany polypharmacy as the patient moves through various sites of care. Make your facility the place where physicians declare “the buck stops here.”
- Redefine the scope of the medications therapy management program to include a focus on polypharmacy. Pharmacists should complete a line-item review of the patient's current meds list, note recommended changes, and present the discharging physician with an optimized list for sign-off and review with the patient. The optimized medications list should then be communicated to the patient's PCP as well as the patient's admitting physician if there is a transition to another facility.
- Engage the patient as early as possible through education and discussion. Where practical, conduct a comprehensive review of the patient's current prescriptions, expired prescriptions still in the cabinet, over-the-counter medications and other supplements. Such a review can be performed electronically or by telephone if necessary, before admissions for planned stays, with the involvement of family members and caregivers.
- Outsource polypharmacy management to experienced medication consultants. An emerging option is for dedicated physicians — with pharmacists’ support — to review patient medical administration records remotely and securely. The consultant functions as an adviser and recommender to the attending physician.The doctor-to-doctor interaction brings speed, scale and expertise to the process while leaving the attending physician in control.
Polypharmacy management and population health
Transition-of-care management is a core component of a successful population health program, and ineffective polypharmacy management must be addressed. A truly optimized medications regimen, in concert with an effective medication therapy management program, should be deeply integrated into the care transition process.
Health system leaders intent on building a population health program would do well to recognize that they are in a good position to avoid polypharmacy. Facilities that assume a proactive role in polypharmacy management with meaningful physician engagement will enjoy a competitive advantage in managing the health of their local populations. They will profit from improved outcomes for their patients while delivering a benefit to all stakeholders across the care continuum.
Todd Kislak is a health care consultant based in Los Angeles.